Case Study help needed, please. re: Endocrine Disorders

[punkydoodlesRN, BSN, RN]

hi, i've asked for help with a case study once before and was give excellant advice! in fact, i got an a on it. so, thank you! now i have another due. we're winding up the semester and i'd love to keep my 'b'

yes, there are still many questions unanswered. i've studied hard during my first 2 semesters and have made excellent grades, however, i still feel like i don't know anything. sometimes i can critically think very well, but often i feel like a deer-in-a-headlight. i am in the lvn program and have a hard time thinking that i will be ready to sit for my nclex and work as a nurse by may!!! is this a normal feeling at this stage or should it be clicking? i sat with my instructors last week one-on-one just to discuss this - they all gave me crazy looks. the seem to think that i have what it takes and that i'm just worried about nothing. but i am worried. i would think by the end of the 2nd semester i could fill out a case study with out shedding any tears? but, notsomuch.

case study:

yl makes an appointment to come to the clinic where you are employed. she has been complaining of chronic fatigue, increased thirst, constant hunger and freq urination. she denies any pain, burning or low-back pain on urination. she tells you that she has a lady partsl yeast infection that she has treated numerous times with otc medication. she admits to starting smoking since going back to work full time as a clerk in a loan company. she also complains of having difficult reading numbers and reports making frequent mistakes. she says "by the time i get home and make supper for my family, then put my child to bed, i am too tired to exercise" she reports her feet hurt; they often "burn or feel like there are pins in them" she reports that, after her delivery, she went back to her traditional eating pattern, which is high in cho

in reviewing yl chart, you notice she has not been seen since the delivery of her child 6 years ago. she has gained considerable wt, her current wt is 173 lbs. today, her bp is 152/97 and her plasma glucose is 291. her pcp orders the following labs: us hba1, fasting cmp, cbc, fasting lipid profile and gfr. the lab values are as follows: fasting glucose 184, hba1 10.4, ua+glucose, -ketones, cholesterol 256, triglycerides 346, ldl 155, hdl 32, ration 8.0 a subsequent fasting glucose is also elevated, and yl is diagnosed with type 2 diabetes mellitus.

after meeting with yl and discussing management therapies, the pcp decides to start multiple does injection insulin therapy and have the patient count cho. yl is scheduled for education classes and is to work with the diabetes team to get her blood glucose under control.

1. id 3 methods used to diagnose dm

fasting blood glucose

hb a1 (?)

????

2. id 3 functions of insulin

regulates glucose metabolism

stimulates lipogenesis

stimulates growth

3. insulin's main action is to lower blood glucose levesl. several hormones produced in the body inhibit the effects of insulin. id 3

4. yl was started on lispro and glargine insulin with cho counting. what is the most important point to make when teaching the pt about glargine

5. because yl has been on regular insulin in the past, you want to ensure she understands the difference between regular and lispro. what is the most significant difference between these two insulins

6. what is the peak time and duration for lispro insulin

peak: 1-2 hours

duration: 3-5 hours

7. yl wants to know why she can't take nph and regular insulin. she is more familiar with them and has taken them in the past. explain the advantages of glargine and lispro over nph and regular insulin

advantage of glargine: it provides patients a longer duration of insulin (24hours), therefore, decreases the risk for nocturnal hypoglycemia.

advantage of lispro:???

8. yl's culture prefers foods high in cho. what is cho counting and why would this method work well for yl

cho counting is a method for controlling the amount of cho you eat at meals and snacks. by counting carbohydrates in food, you can control the portion you have in every meal and the total you have for the day. it will help yl improve her blood glucose control (which will decrease risk for future complications) and help her to better interpret her blood glucose readings.

9. which of the symptoms that yl reported today led you to believe she has some form of neuropathy

c/o burning feet with the sensation of pins pricking in them

10. what findings in yl's history place her at increased risk for the development of other forms of neuropathy

11. what are some changes that yl can make to reduce the risk or slow the progression both macrovascular and microvascular disease

12. yl is enrolled in a smoking cessation class. what is it so important that she stop smoking

smoking raises blood sugar levels and decreases body's ability to use insulin, making it hard to control diabetes. [color=#474a51]other complications of smoking on diabetes include retinopathy (eye disease), heart disease, stroke, vascular disease, kidney disease, nerve damage, foot problems, and many others

so, i would appreciate any guidance on this. not even straight answers, just some nudging toward the right direction....

thank you

a student who wants to be a nurse really (really) bad :)

[SheaTab]

Hi Punky!

I'd love to offer some thoughts, if I may.

First, this patient will need a lot of nursing support to get a handle on her disease process before it progresses further and frequent follow-up and support will be instrumental.

In terms of her history, take a look at her Hemoglobin A1c. Her number is concerning because it indicates that her blood sugar has been way too high over the past few months. The A1c is an indication of glycosylation in the body which is damaging to the blood vessels and peripheral nerves. It causes thickening of the basement membrane which will impair oxygen transport to the tissues and carbon dioxide removal. Oxygen is the source of all life to all living tissues. Any pathologic condition that affects the delivery of oxygen will eventually result in cell damage and ultimately death if not corrected. This is why you will see poor wound healing and necrotic lesions in diabetics. Their circulation to distal tissues (feet, for example) is impaired because of glycosylation. Her high HgbA1c is an indication of increased risk for neuropathy and micro/macrovascular damage.

Her smoking will also have an effect on her blood vessels. Remember that all of these problems have a compounding and cumulative effect. Cigarettes will cause vasoconstriction and cardiovascular disease in addition to all known cancers.

My goodness, look at her BP! She is hypertensive. In addition to hyperglycemia and cigarettes, her BP is wreaking havoc on her organs. She will need to keep a journal of her BPs and might need antihypertensive management in addition to her insulin regimen. Close followup is indicated here.

Oh yeah, and take a look at her cholesterol. This will further compound her problems because levels like this are probably resulting in plaque accumulation in her vascular system. Her elevated triglycerides are probably resulting from her excessive carb consumption. She may be able to resolve this with dietary management, however, she may require a triglyceride-lowering agent like Tricor. If she is unable to get her LDL down and her HDL up with diet, exercise, and smoking cessation, she may require a statin like Lipitor or Zocor. The AHA guidelines for heart disease patients are: LDL 70, and Trigs

All of her issues need to be treated aggressively with her insulin regimen, diet, exercise, smoking cessation, and weight loss. If these interventions don't result in significant improvements, she will need pharmaceutical intervention for her cholesterol and BP. Also, you might suggest smoking cessation counseling and/or a pharmaceutical treatment option to get her off of this horribly addictive substance.

Hey! Kudos to you for really trying to get a grasp on this amazingly complex and fascinating human body of ours! Nice work on your critical thinking.

Also, consider recommending a diet rich with complex carbohydrates like fresh veggies. She will need to go very easy on the flesh products and should stick with fish and very lean poultry. Rarely beef. The Mediterranean diet is a great option for diabetics because it emphasizes complex carbs, healthy fats (Omegas and monounsaturated) and just a little in the lean meat department. Complex carbs and fiber will help bring her cholesterol down as well. Also, consider recommending adding antioxidants into her diet daily. She can have a serving of fresh blueberries on top of a bowl of oatmeal. Be careful with antioxidant-rich juices because they are high in natural sugars. Her main beverage of choice would be water.

I hope this helps!

Keep rocking!

Tabitha

[punkydoodlesRN, BSN, RN]

Thank you Tabitha!!

[punkydoodlesRN, BSN, RN]

What about the following questions? Does anyone have any insight for me? I'm still struggling with this case study

3. Insulin’s main action is to lower blood glucose levesl. Several hormones produced in the body inhibit the effects of insulin. Id 3

4. YL was started on lispro and glargine insulin with CHO counting. What is the most important point to make when teaching the pt about glargine

5. Because yl has been on regular insulin in the past, you want to ensure she understands the difference between regular and lispro. What is the most significant difference between these two insulins

Advantage of lispro:???

11. What are some changes that YL can make to reduce the risk or slow the progression both macrovascular and microvascular disease

[punkydoodlesRN, BSN, RN]

Bumping... I'm still not getting these last answers and I've exhausted all of my reference books. This is due tomorrow and I just don't know where else to looking. Hoping for a bit more insight on this one.

Thanks!

Sarah